A National Guideline for Palliative Sedation in The Netherlands

Abstract

The first national guideline on palliative sedation in The Netherlands has been adopted by the General Board of the Royal Dutch Medical Association. By law, the physician is obliged to take this guideline into consideration. In this paper, we present the main principles of the guideline. Palliative sedation is defined as the intentional lowering of consciousness of a patient in the last phase of his or her life. The aim of palliative sedation is to relieve suffering, and lowering consciousness is a means to achieve this. The indication for palliative sedation is the presence of one or more refractory symptoms that lead to unbearable suffering for the patient. Palliative sedation is given to improve patient comfort. It is the degree of symptom control, not the level to which consciousness is lowered, which determines the dose and the combinations of the sedatives used and duration of treatment. Palliative sedation is normal medical practice and must be clearly distinguished from the termination of life.

Ethical dilemmas faced by hospice nurses when administering palliative sedation to patients with terminal cancer

“…The authors identified inconsistencies and a lack of clarity on what constituted "intolerable" or "refractory" suffering and proposed that the patient's ability to consent should be explicitly recorded, that the team have a shared and explicit understanding of the terminology and definitions of sedation, and that formal mechanisms for support (such as clinical supervision) are offered to staff. The development of guidelines has become a focus and priority due to concerns and uncertainty surrounding decisionmaking dilemmas and the connotations and inferences related to euthanasia and palliative sedation (Abarshi et al, 2014;Schildmann & Schildmann, 2014;Cherny & Radbruch, 2009;Hauser & Walsh, 2009;Legemaate et al, 2007;Verkerk et al, 2007;de Graeff & Dean, 2007;Engström et al, 2006).…”

Palliative sedation: Why we should be more concerned about the risks that patients experience an uncomfortable death

“…Paradoxically, the inability to report distress might also be 159 aggravated or even blocked by the use of drugs that might abolish 160 potential further communication and even facial expressions [9]. Palliative sedation is normal medical practice and must be clearly distinguished from the termination of life [35] Proportionality: the degree of sedation must not be deeper than necessary to relieve suffering [11,12,23,35] Palliative sedation will not (usually) hasten death (and that is certainly not the intention) [ [24] o ''Monitoring (observational) scales exist but the usefulness of these scales has not been proven'' [16] o ''Presently no particular scale can be recommended'' [16,24] ''Scales involving administration of painful stimuli are not acceptable'' [16] Frequency of monitoring: every 20 minutes until adequate sedation has been reached and then at least once a day [15,16] Nurses have the explicit task to observe, measure, and report [24] 161 Hence, some patients might have subjective phenomenological …”

Sedación paliativa (parte II): Cuestiones éticas y principios morales

“…Algunos autores han propuesto que la descontinuación de la hidratación y nutrición serían un componente típico o esencial de la técnica de sedación en la etapa final de la vida (38)(39)(40)(41)(42). Es así como Rietjens, por ejemplo, introduce este aspecto en la misma definición de "sedación terminal", que para ese autor sería la administración de drogas para mantener al paciente en sedación profunda o coma hasta la muerte, sin darle nutrición o hidratación artificial(37:179).…”